Pharmacy's role is vital when pandemics bioterrorism are involved

Create pharmacy business continuity plan

Pharmacists need to take an active leadership role in developing emergency preparedness plans, volunteering as first responders, and staging disaster drills, according to a variety of experts on disaster planning.

The latest wisdom regarding national disaster preparedness suggests that pharmacists should be available at points of medication and vaccine distribution, and they should be viewed as partners during emergency situations, especially when the emergency involves bioterrorism or an infectious disease outbreak.

But it will take pharmacists at hospitals and elsewhere to step up and volunteer for these leadership roles before they are fully integrated into the emergency preparedness activities of any particular city or region.

"The joke is that if pharmacists don't step up and say, 'We want to work at these points of distribution, then they'll be standing in lines receiving drugs from schoolteachers," says Carsten Evans, PhD, FASHP, an assistant dean in continuing professional education in the college of pharmacy at Nova Southeastern University.

Pharmacists should volunteer for emergency services as a point of pride, some suggest.

"Honestly, it would be embarrassing if I needed to go to a point of dispensing to pick up an antibiotic and there were few or no pharmacists involved in dispensing the drug," says Erin Mullen, RPh, PhD, assistant vice president for Rx Response in Washington, DC. Rx Response is a private sector partnership of organizations that span the pharmaceutical supply chain. The organization helps to ensure the continued provision of critical medications in times of a public health emergency.

Hospitals nationwide are becoming better trained, educated, and prepared to handle an infectious disease disaster, such as a pandemic influenza outbreak.

For instance, some hospitals and health care providers participate in a database of electronic syndrome surveillance, which collects chief medical complaints that can be tracked and monitored for trends, such as abnormally high flu-like symptoms, says Sharon S. Cohen, RN, MSN, CEN, CCRN, an emergency preparedness clinical nurse specialist/instructor trainer at Broward Health in Fort Lauderdale.

"An epidemiologist will look at all participating hospitals' data to see if there's a spike outside the norm," Cohen says.

"We know that entering the flu season there will be respiratory events," she notes.

But the key is for an expert to see if there are any trends that are outside the expected.

"I do believe history repeats itself," Cohen says. "Look at the history of various flu epidemics, such as the 1918 influenza pandemic, which killed a huge population."

Now with mass travel across borders, there's the potential for a respiratory vector to cross borders within hours, Cohen adds.

"There are many routes to possible transmission or exposure," she says.

Pharmacists need to be part of the planning process for infectious disease outbreaks and other disasters.

They also should know their own roles and responsibilities in major emergencies and in situations that require an evacuation, says Richard G. Thomas, PharmD, DABAT, emergency management coordinator for Phoenix Children's Hospital in Phoenix, AZ.

"The pharmacy needs to have a plan that would fit in with the hospital's evacuation plan to make sure that patients who are being transferred have the medications they need," Thomas says.

For instance, at Phoenix Children's Hospital, there are some pharmaceutical preparations made that no one outside the hospital can prepare, he notes.

"So it's particularly important for us to be able to have those medications go with the child in the event of an evacuation," Thomas says. "They may not have access to community pharmacists to get the medications they need, which is why pharmacists need to know what their hospital's disaster plan is and how they would fit into that plan."

The other thing pharmacists should do is write a business continuity plan for their department, Thomas says.

"This basically is a plan which has a hazard vulnerability assessment and additional analysis of what are the key business activities in which pharmacists engage," Thomas says.

"You go down the list of things the pharmacy does and then look at hazards from the hazard vulnerability assessment and look at your own department's track records of what things have affected you in the past," Thomas says. "Once you know what the steps are and what resources you need, you say, 'Based on the hazards, what do we need to do to make sure we can continue to provide the service if one of those hazards happen?'"

Solutions might be to train more technicians so if one or more are unavailable, the service can continue or to find a back-up supplier in case the regular supplier is unable to make a delivery during an emergency.

"By doing that, you can hopefully deliver that service or product regardless of what happens," Thomas says. "It might not be at the same capacity or same level of service, but if you provide a minimal level of service, you have accomplished your goal."

Hospital pharmacists also should make a habit of drilling their own department for vulnerabilities, suggests Deborah J. Larison, PharmD, BCPS, a clinical pharmacy specialist in emergency medicine at Sarasota Memorial Hospital in Sarasota, FL.

This could be as simple as making a plan for what to do when the printers go out and labels need to be either hand-printed or printed through a back-up system, Larison says.

Another strategy is to develop disaster cards that tell staff which job functions each person has for today and what the job duties are under each function, Larison says.

"The hospital's emergency codes are posted all around the institution, but individual cards that tell you your job function during an event are posted upstairs in the pharmacy with our disaster information," Larison adds.

Also, pharmacists need to plan how to stockpile items, like personal protective equipment, needed in the case of a disaster, Larison notes.

"The CDC's plan for pandemic influenza does not recommend that we stockpile medicines, but they recommend that we stockpile personal protective equipment," she explains. "Whether there's an avian flu pandemic or regular seasonal influenza with a bad outbreak, we need to know how much we need and how we rotate the personal protective equipment appropriately."

Public health officials and others would like pharmacists to join the medical reserve corp in their counties' health departments, Evans says.

"You have to go to the health department to find out how to be in the medical reserve corp," he adds.

Hospital pharmacists also can become more personally involved in emergency preparedness by becoming educated on bioterrorism and radiological terrorism, Mullen says.

Pharmacists who are trained and educated about bioterrorism events could be very helpful in planning for an emergency, such as an aerosolized anthrax attack, she says.

"One of the principles of emergency management is that all disasters are local first, and then they become regional, state, and finally as everyone becomes overwhelmed, they reach out to the federal government," Evans says. "That's how a bioterrorism event is recognized — first locally."

For example, when some people were victims of anthrax exposure about seven years ago, the first presentation in hospitals were of sudden pneumonia. The earliest victims were diagnosed too late to be saved.

A knowledgeable pharmacist could assist with a speedy diagnosis, Evans says.

One resource for pharmacists interested in learning more about emergency preparedness is an educational course called "Emergency Preparedness: Pharmacists as First Responders," which is offered annually by Nova Southeastern University College of Pharmacy in Fort Lauderdale, FL.

The Centers for Disease Control and Prevention (CDC) of Atlanta, GA, is holding states accountable for having plans that would deliver oral antibiotics within 48 hours of an airborne anthrax attack, and that time includes requesting the antibiotic from the CDC and delivering it into the hands of each citizen, Evans says.

"Early recognition could mitigate it," Evans notes.

Also, the U.S. Department of Health and Human Services announced a new plan in October 2008 for distributing antibiotics in the event of an anthrax attack: Volunteer letter carriers would be asked to deliver antibiotics in affected communities

The challenge includes having health officials make a diagnosis when the first cases crop up or having a Homeland Security/CDC air filter, which are placed strategically in the United States, to identify the agent before illness occurs.

"There are random air monitors that take randomized samples and check them every 24-48 hours to see what they are," Cohen says.

"If there's a sample with a positive hit, we monitor for any new respiratory complications, new patients on ventilators," Cohen adds. "We're much further along in our surveillance and rapid identification because we're much more frequently sampling air and soil and water quality than we have been before."

Pharmacists also are needed once a medication is dispensed to a large group or population of people because someone will need to answer multiple questions about drug interactions and side effects, Evans says.

"So much of preparedness fits into good pharmacy practice and is what we should be doing anyway," Evans says. "Make sure people are filling their prescriptions and know what they're for."

"Pharmacists need to make sure there are no additional contraindications or drug interactions," Cohen says. "And for anthrax, we give out ciprofloxacin, but if there are allergies or contraindications, then a pharmacist will make a recommendation for the next best antibiotic."